Use Of Tissue Plasminogen Activator Research Articles

Abstract TMP79: Use of Intravenous Tissue Plasminogen Activator in Patients With History of Prior Stroke Plus Diabetes Mellitus

Background: Patients with history of diabetes mellitus (DM) plus prior ischemic stroke were excluded from ECASS III trial due to safety concerns. However, there are few data on use of intravenous tissue plasminogen activator (IV tPA) and risk of symptomatic intracranial hemorrhage (sICH) or outcomes in this population. Methods: Using data from the Get With The Guidelines-Stroke Registry (GWTG-Stroke) between February 2009 and September 2017 (n=1619 hospitals), we examined characteristics and outcomes among AIS patients treated with tPA within the 3-4.5 hour window who had a history of prior stroke and DM (n=2129) versus those without either history (n=16,690). Results: Compared with patients without either history, those with prior stroke and DM had a higher prevalence of cardiovascular risk factors and more severe stroke (Table). The unadjusted rates of sICH and in-hospital mortality were 4.3% vs 3.8% and 6.2% vs 5.5%, respectively. These differences were not statistically significant after risk adjustment (sICH, adjusted odds ratio [OR] 0.79[95% CI, 0.51-1.21], p=0.28; in-hospital mortality OR 0.77 [95% CI, 0.52-1.14], p=0.19). Unadjusted rate of functional independence (Modified Rankin Scale score [mRS] 0-2) at discharge was lower in those with history of prior stroke and diabetes (30.9% vs 44.8%, p=<0.0001), this difference persists after adjusting for baseline clinical factors (adjusted OR 0.76 [95% CI, 0.59-0.99], p=0.04). During the study period, there were 339 patients otherwise eligible for IV tPA, arriving within 0-3.5 hours, but not treated with IV tPA due to history of prior stroke and DM. Conclusion: Among AIS patients treated with intravenous tPA within the 3-4.5 hour window, history of prior stroke plus DM was not associated with statistically significant increased sICH or mortality risk.

Gender and thrombolysis therapy in stroke patients with incidence of dyslipidemia

BackgroundWhen untreated, dyslipidemia is a higher risk factor for stroke and stroke-related mortality in men than in women. However, when dyslipidemia is treated the risk reduction is the same, but men benefited from mortality reduction more than women. Whether there is a gender difference in exclusion criteria for the use of recombinant tissue plasminogen activator (rtPA) or thrombolysis therapy in an acute ischemic stroke subpopulation with dyslipidemia is yet to be investigated.MethodIn a dyslipidemic stroke population obtained from a stroke registry, gender differences in exclusion risk factors were determined using clinical and demographic variables. Univariate analysis compared the recombinant tissue plasminogen activator (rtPA) group and the no rtPA group. Multiple regression analysis was used to determine demographic and clinical factors associated with inclusion and exclusion for rtPA in the total dyslipidemic stroke population and the subsets of the male and female population. The regression model was tested using the Hosmer-Lemeshow test, for the overall correct classification percentage. Significant interactions and multicollinearity between independent variables were examined using variance inflation factors.ResultsA total of 769 patients presented with acute ischemic stroke with incidence dyslipidemia; 325 received rtPA while 444 were excluded from rtPA. Of those excluded from rtPA, 54.30% were female and 45.72% were male. In an adjusted analysis, female patients with increased age (OR = 1.024, 95% CI, 1.001–1.047, P < 0.05), with a history of carotid artery stenosis (OR = 7.063, 95% CI, 1.506–33.134, P < 0.05), and previous stroke (OR = 1.978, 95% CI, 1.136–3.442, P < 0.05) were more likely to be excluded from rtPA. Male patients with atrial fibrillation (OR = 2.053, 95% CI, 1.059–3.978, P = 0.033), carotid artery stenosis (OR = 2.400, 95% CI, 1.062–5.424, P = 0.035), and previous stroke (OR = 1.785, 95% CI, 1.063–2.998, P = 0.028) were more likely to be excluded from rtPA.ConclusionAlthough there are some similarities in the clinical risk factors for exclusion in both male and female stroke patients with incidence of dyslipidemia, there are differences as well. Elderly female stroke patients with incidence of dyslipidemia are more likely to be excluded from rtPA, even after adjustment for the effect of confounding variables. Further research should focus on how identified clinical risk factors can be targeted and managed to improve the use of rtPA in elderly female acute ischemic stroke population with incidence of dyslipidemia.

Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience.

BackgroundThe use of intravenous recombinant tissue plasminogen activator (IV r-tPA) in early acute ischemic stroke (AIS) management faces a lot of difficulties in developing countries due to lessened guideline development with consecutive pre- and intra-hospital delay.ObjectivesThe objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals.MethodsThe study was conducted on 4124 AIS patients eligible to use IV r-tPA divided to group-I consisting of 442 patients who arrived the hospital within <3.5 h from the stroke onset and group-II consisting of 3682 patients who arrived >3.5 h from the stroke onset. The former group was further subdivided to 238 patients who received IV r-tPA (group-Ia) and 204 patients who did not receive IV r-tPA (group-Ib) due to different obstacles.ResultsThe main causes of pre-hospital onset to arrival delay were stroke unawareness, long travel time, incorrect beliefs, non-available neurologists, stroke onset during sleep and multiple causes (18.2%, 20.5%, 12.7%, 9.1%, 16% and 23.5% of cases, respectively). Causes of non-administration of IV r-tPA in eligible patients includes prolonged door-to-needle time, financial restraints, minor strokes, unavailable beds and fear of complications (41.2%, 26%, 12.7%, 11.3% and 8.8%, respectively).ConclusionIncreasing the chance of utilizing IV r-tPA for AIS patients' needs regular updating of the stroke chain of survival system to get the highest benefits from the available resources.

Treatment for ischemic stroke: From thrombolysis to thrombectomy and remaining challenges.

Stroke is a leading cause of death and long-term disabilities. Despite decades of extensive efforts in search of brain injury mechanisms and therapeutic interventions, pharmacological treatment is limited to the use of thrombolytic agent tissue plasminogen activator, which has limited therapeutic time window and potential side effect of intracranial hemorrhage. Over the past few years, endovascular thrombectomy with stent-retriever devices combined with advanced imaging modalities has transformed the standard of stroke care, offering an opportunity to improve the outcome in selected patients as late as 24 h after the onset of stroke. This mini-review summarizes the advancement in the treatment of ischemic stroke, from thrombolysis to thrombectomy and remaining challenges in the field.

Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism.

There have been significant advancements in the management of intracerebral hemorrhage (ICH) stemming from new knowledge on its pathogenesis. Major clinical trials, such as Surgical Trial in Lobar Intracerebral Hemorrhage (STICH I and II), have shown only a small, albeit clinically relevant, advantage of surgical interventions in specific subsets of patients suffering from ICH. Currently, the aim is to use a minimally invasive and safe trajectory in removing significant brain hematomas with the aid of neuro-endoscopy or precise guidance through neuro-navigation, thereby avoiding a collateral damage to the surrounding normal brain tissue. A fundamental rational to such approach is to safely remove hematoma, preventing the ongoing mass effect resulting in brain herniation, and to minimize deleterious effects of iron released from hematoma to brain cells. The clot lysis process is facilitated with the adjunctive use of recombinant tissue plasminogen activator and sonolysis. Revised recommendations for the management of ICH focus on a holistic approach, with special emphasis on early patient mobilization and graded rehabilitative process. There has been a paradigm shift in the management algorithm, putting emphasis on early and safe removal of brain hematoma and then focusing on the improvement of patients' quality of life. We have made significant progress in transition from nihilism toward optimism, based on evidence-based management of such a severe global health scourge as intracranial hemorrhage.

The Risk of Symptomatic Intracranial Hemorrhage after Thrombolysis for Acute Stroke: Current Concepts and Perspectives.

Background:Thrombolysis is the standard of treatment for acute ischemic stroke, with a time window of up to 4½ h from stroke onset. Despite the long experience with the use of recombinant tissue plasminogen activator and the adherence to protocols symptomatic intracranial hemorrhage (SICH) may occur in around 6% of cases, with high-mortality rate and poor-functional outcomes. Many patients are excluded from thrombolysis on the basis of an evaluation of known risk factors, but there are other less known factors involved.Objective:The purpose of this work is to analyze the less known risk factors for SICH after thrombolysis. A search of articles related with this field has been undertaken in PubMed with the keywords (brain hemorrhage, thrombolysis, and acute ischemic stroke). Some risk factors for SICH have emerged such as previous microbleeds on brain magnetic resonance imaging, leukoaraiosis, and previous antiplatelet drug use or statin use. Serum matrix metalloproteinases have emerged as a promising biomarker for better selection of patients, but further research is needed.Conclusions:In addition to the already known risk factors considered in the standard protocols, an individualized evaluation of risks is needed to minimize the risk of brain hemorrhage after thrombolysis for ischemic stroke.

Expansion Of Telestroke Services Improves Quality Of Care Provided In Super Rural Areas.

Telestroke is a telemedicine intervention that facilitates communication between stroke centers and lower-resourced facilities to optimize acute stroke management. Using administrative claims data, we assessed trends in telestroke use among fee-for-service Medicare beneficiaries with acute ischemic stroke and the association between providing telestroke services and intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy use, mortality, and medical expenditures, by urban versus rural county of residence in the period 2008-15. The proportion of ischemic stroke cases receiving telestroke increased from 0.4 to 3.8 per 1,000 cases, with usage highest among younger, male, non-Hispanic white, and patients in rural or super rural areas (super rural is the bottom quartile of rural areas. Compared with patients receiving usual care, those receiving telestroke had greater IV tPA and mechanical thrombectomy use regardless of county type, while those in super rural counties had lower thirty-day all-cause mortality. Despite increased telestroke use, rural patients remained less likely than urban patients to receive IV tPA. The findings suggest that telestroke service expansion efforts have increased, especially in rural and super rural counties, and have improved outcomes.

Peripherally Inserted Central Catheters (PICCs), the Leading Cause of Central Venous Catheter Associated Thrombosis in Children

IntroductionCentral venous catheters (CVC) are necessary for medically complex and acutely ill children, but come with the risk of venous thromboembolism (VTE) or central line associated blood stream infection (CLABSI). The rate of VTE in pediatrics has increased, most likely due to the increased use and placement of CVCs, and questions remain regarding VTE risk factors for CVC associated thrombosis.MethodsThis prospective, multi-center study compared the incidence and risk factors for VTE between peripherally inserted central catheters (PICCs) and centrally inserted tunneled lines (TLs) in patients 6 months to <18 years from 4 pediatric hospitals from September 2013 to April 2018. Data were collected through medical record review regarding demographics, medical history and specific CVC data including insertion technique and catheter specifications. Subjects were prospectively monitored via medical record review for CVC complications including VTE, CLABSI or malfunction (use of tissue plasminogen activator, malposition, blockage, etc).Cumulative incidence rates of VTE, CLABSI, CVC malfunction and removal were estimated and compared between PICCs and TLs. These analyses focused on the first 6 months from CVC insertion using parametric survival models assuming a Weibull survival distribution. The association between occurrence of VTE and subject/CVC characteristics was first assessed in univariate analyses, and then assessed by a minimal multivariable model.ResultsA total of 1,969 CVCs from 1,744 unique patients were included. Median age at CVC insertion was 6.4 years (range: 0.6-17.9) with the majority, 1048 (53%) placed in males. PICCs made up 1,259 (64%) of the CVCs and 710 (36%) were TLs.Among 1,969 CVCs, 100 had a VTE with a cumulative incidence rate of 5.4±0.5%, and median time to VTE from CVC insertion was 0.6 months (range 0-5.8 months). Eighty percent of the VTEs were in PICCs and median time to VTE was 0.5 months (range 0-5.3 months) in PICCs compared to TLs with a median time to VTE of 1.4 months (range 0-5.8 months). The incidence rate of VTE was 2.9±0.6% for TLs, and 6.8±0.7% for PICCs (Figure 1). In univariate analysis, subjects with TLs had a significantly lower risk of developing a VTE than patients with PICCs (HR=0.14, 95%CI: 0.05-0.4, p<0.001).The incidence of CLABSI was 14±1.3% for TLs compared to 7.9±0.9% for PICCs and in univariate analysis CVCs with a CLABSI were 4 times (95%CI: 1.3-13) as likely to develop a VTE. The cumulative incidence of malfunction in all CVCs was 25±1.0%, and univariate analysis revealed CVCs with a malfunction were 10 times (95%CI: 3.6, 28) as likely to develop a VTE.In the multivariable analyses (Table 1), subjects with TLs were significantly less likely to develop a VTE compared to PICCs (HR=0.16, 95%CI: 0.06-0.4, p<0.001); subjects with leukemia were more likely to have a VTE than subjects without cancer or other cancer diagnosis (HR=3.6, 95%CI: 1.3-9.9, p=0.050); subjects with a previous history of VTE were significantly more likely to develop a new VTE (HR=36, 95%CI: 6.3-210, p<0.001); and compared to CVCs with 1 lumen, CVCs with 2-3 lumens resulted in a higher risk of developing a VTE (HR=4.4, 95%CI: 1.9-10, p=0.002). Diagnosis of a CLABSI (HR=6.3, 95%CI: 2.1-18, p<0.001) as well as CVC malfunction (HR=5.7, 95%CI: 2.3-14, p<0.001) were also associated with higher risk of developing a VTE.ConclusionThis study represents the first prospective evaluation of the incidence and risk factors of VTE for TLs and PICCs placed in children. Almost 2,000 CVCs are included in this final analysis, which revealed a significant increase in VTE risk for children who have a PICC placed compared to a TL. The greatest risk factor for CVC associated VTE was a prior history of VTE. Additional risk factors included CLABSI, CVC malfunction, leukemia and having a multi-lumen CVC.Even though the ease of placing a PICC is enticing to avoid repeat peripheral intravenous (PIV) insertions or surgical intervention with TL placement, the increased risk of VTE in PICCs should give practitioners pause. When CVC placement is unavoidable, limiting the number of lumens is a modifiable VTE risk factor and efforts to prevent CLABSI may reduce VTE incidence. Interestingly, no insertion characteristics (e.g. placement vein, access side, catheter brand or material, tip location, insertion attempts) were associated with an increased risk of VTE. [Display omitted] DisclosuresJaffray:Octapharma: Consultancy; CSL Behring: Consultancy, Research Funding; Bayer: Consultancy. Young:Kedrion: Consultancy; Genentech/Roche: Consultancy, Honoraria; CSL Behring: Consultancy, Honoraria; Bioverativ: Consultancy, Honoraria; Bayer: Consultancy; Novo Nordisk: Consultancy, Honoraria; Shire: Consultancy, Honoraria.

Central Venous Catheter-associated Venous Thromboembolism in Children With Hematologic Malignancy.

In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous catheter (CVC) have been identified as significant risk factors for the development of a venous thromboembolism (VTE). There remain little data regarding CVC factors associated with CVC-related VTE. Using the VTE and oncology database in a quaternary care center, a retrospective cohort study was conducted in children below 18 years old with hematologic cancer from November 5, 2012 to April 4, 2016. Patient, CVC factors, and VTE occurrence were analyzed to identify significant patient and CVC factors associated with the development of clinically identified CVC-related VTE. Utilizing the χ, Mann-Whitney, and the Fisher exact tests, patient factors were compared across VTE yes/no groups. Of the 198 study patients, 22 VTE cases were identified. Eighteen VTE events were CVC-associated, occurring in 9% of study population. Peripherally inserted central catheter lines and older ages were associated with VTE. The use of tissue-plasminogen activator for CVC occlusion was associated with decreased VTE rates, suggesting a protective potential.

Safety of Endovascular Thrombectomy for Acute Ischaemic Stroke in Anticoagulated Patients Ineligible for Intravenous Thrombolysis

Background/Aim: Endovascular thrombectomy may be performed in anticoagulated patients taking vitamin-K antagonists (VKA) or direct-acting oral anticoagulants (DOAC) in whom the use of intravenous tissue plasminogen activator (tPA) is contraindicated. We aimed to investigate the efficacy and safety of mechanical thrombectomy specifically in anticoagulated patients ineligible for thrombolysis. Methods: We performed a retrospective analysis of a prospectively collected database of consecutive ischaemic stroke patients undergoing mechanical thrombectomy from January 2008 to June 2017. Patients receiving any dose of intravenous or intra-arterial thrombolysis were excluded. Patients taking oral anticoagulants (VKAs or DOACs) were compared with non-anticoagulated patients. Outcomes compared between groups included the rate of intracerebral haemorrhage (ICH) on follow-up imaging (ICHany), symptomatic ICH, functional independence at 90 days (modified Rankin scale score, 0–2), mortality, and post-treatment recanalization (Thrombolysis in Cerebral Infarction score ≥2b). Results: In all, 102 patients undergoing mechanical thrombectomy without prior thrombolysis were included in the study. Sixty-six (64.7%) patients were not anticoagulated, 23 (22.5%) patients were taking VKAs, and 13 (12.7%) patients were taking DOACs. There were no significant differences in the rate of ICHany (11.1 vs. 13.6%, p = 0.93) or sICH (2.8 vs. 1.5%, p = 0.14) in anticoagulated patients compared to non-anticoagulated patients. No cases of sICH were observed among patients taking DOACs. After 90 days of follow-up, the rates of functional independence (50.0 vs. 43.1%) and mortality (27.8 vs. 25.8%) were also similar between the anticoagulation and the non-anticoagulation groups. Conclusion: Mechanical thrombectomy appears to be safe and effective in anticoagulated patients ineligible for thrombolysis, with observed haemorrhage rates similar to those of patients not on anticoagulant therapy. However, further multicentre prospective studies are needed, due to the rising number of patients on warfarin and DOACs worldwide.

Quality of Care and Outcomes for Patients With Stroke in the United States Admitted During the International Stroke Conference.

BackgroundPatients presenting to hospitals during non–weekday hours experience worse outcomes, often attributed to reduced staffing. The American Heart Association International Stroke Conference (ISC) is well attended by stroke clinicians. We sought to determine whether patients with acute ischemic stroke (AIS) admitted during the ISC receive less guideline‐adherent care and experience worse outcomes.Methods and ResultsWe performed a retrospective cohort study of US hospitals participating in Get With The Guidelines–Stroke and assessed use of intravenous tissue plasminogen activator, other quality measures, and outcomes for patients with AIS admitted during the ISC compared with those admitted the weeks before and after the conference. A total of 69 738 patients with AIS were included: mean age, 72 years; 52% women; 29% nonwhite. There was no difference between the average weekly number of AIS cases admitted during ISC weeks versus non‐ISC weeks (1984 versus 1997; P=0.95). Patient and hospital characteristics were similar between ISC and non‐ISC time periods. There were no significant differences in 14 quality metrics and 5 clinical outcomes between patients with AIS treated during the ISC versus non‐ISC weeks. Patients with AIS who presented within 2 hours of onset had no difference in the likelihood of receiving intravenous tissue plasminogen activator within 3 hours (adjusted odds ratio, 0.89; 95% confidence interval, 0.77–1.03; P=0.13) or the likelihood of receiving intravenous tissue plasminogen activator within 60 minutes of arrival (adjusted odds ratio, 0.92; 95% confidence interval, 0.83–1.02; P=0.13).ConclusionsPatients with acute stroke admitted to Get With The Guidelines–Stroke hospitals during ISC received the same quality care and had similar outcomes as patients admitted at other times.

Principles of Neurologic Ethics

Neuroethics refers to the branch of applied bioethics pertaining to the neurosciences and emerging technologies that impact our ability to understand or enhance a human mind. In the setting of emergency medicine, the clinician will encounter neuroethical dilemmas pertaining to the acutely brain injured or impaired; similar to other ethical decisions encountered in emergency medicine, such neuroethical dilemmas are often complicated by insufficient information regarding the patient’s wishes and preferences and a short time frame in which to obtain this information. This review examines the basis of neuroethics in emergency medicine; neuroethical inquiry; the neuroscience of ethics and intuition; issues regarding autonomy, informed consent, paternalism, and persuasion; shared decision making; situations in which decision-making capacity is in question; beneficence/nonmaleficence; incidental findings and their implications; risk predictions; and issues of justice. The figure shows the use of tissue plasminogen activator (t-PA) for cerebral ischemia within 3 hours of onset and changes in outcome due to treatment. Tables list common ethical theories, virtues/values of an acute care provider, components of informed consent discussion unique to t-PA in acute ischemic stroke, models of the physician-patient relationship, eight ways to promote effective shared decision making, components of capacity assessment, and emergency department assessment of futility. This review contains 1 figure, 9 tables, and 90 references. Keywords: Ethics, autonomy, shared decision-making, moral dilemmas, framing, decision-making capacity, beneficence and nonmaleficence

Principles of Neurologic Ethics

Neuroethics refers to the branch of applied bioethics pertaining to the neurosciences and emerging technologies that impact our ability to understand or enhance a human mind. In the setting of emergency medicine, the clinician will encounter neuroethical dilemmas pertaining to the acutely brain injured or impaired; similar to other ethical decisions encountered in emergency medicine, such neuroethical dilemmas are often complicated by insufficient information regarding the patient’s wishes and preferences and a short time frame in which to obtain this information. This review examines the basis of neuroethics in emergency medicine; neuroethical inquiry; the neuroscience of ethics and intuition; issues regarding autonomy, informed consent, paternalism, and persuasion; shared decision making; situations in which decision-making capacity is in question; beneficence/nonmaleficence; incidental findings and their implications; risk predictions; and issues of justice. The figure shows the use of tissue plasminogen activator (t-PA) for cerebral ischemia within 3 hours of onset and changes in outcome due to treatment. Tables list common ethical theories, virtues/values of an acute care provider, components of informed consent discussion unique to t-PA in acute ischemic stroke, models of the physician-patient relationship, eight ways to promote effective shared decision making, components of capacity assessment, and emergency department assessment of futility. This review contains 1 figure, 9 tables, and 90 references. Keywords: Ethics, autonomy, shared decision-making, moral dilemmas, framing, decision-making capacity, beneficence and nonmaleficence

Principles of Neurologic Ethics

Neuroethics refers to the branch of applied bioethics pertaining to the neurosciences and emerging technologies that impact our ability to understand or enhance a human mind. In the setting of emergency medicine, the clinician will encounter neuroethical dilemmas pertaining to the acutely brain injured or impaired; similar to other ethical decisions encountered in emergency medicine, such neuroethical dilemmas are often complicated by insufficient information regarding the patient’s wishes and preferences and a short time frame in which to obtain this information. This review examines the basis of neuroethics in emergency medicine; neuroethical inquiry; the neuroscience of ethics and intuition; issues regarding autonomy, informed consent, paternalism, and persuasion; shared decision making; situations in which decision-making capacity is in question; beneficence/nonmaleficence; incidental findings and their implications; risk predictions; and issues of justice. The figure shows the use of tissue plasminogen activator (t-PA) for cerebral ischemia within 3 hours of onset and changes in outcome due to treatment. Tables list common ethical theories, virtues/values of an acute care provider, components of informed consent discussion unique to t-PA in acute ischemic stroke, models of the physician-patient relationship, eight ways to promote effective shared decision making, components of capacity assessment, and emergency department assessment of futility. This review contains 1 figure, 9 tables, and 90 references. Keywords: Ethics, autonomy, shared decision-making, moral dilemmas, framing, decision-making capacity, beneficence and nonmaleficence

Modern Approaches to Evacuating Intracerebral Hemorrhage.

The present review aims to discuss the recent advances in surgical management of spontaneous intracerebral hemorrhage (ICH), safety and efficacy of minimally invasive surgical techniques, and the existing evidence supporting their use. Newer surgical techniques, collectively referred to as minimally invasive surgery (MIS), have been evaluated and studied in management of ICH. Stereotactic evacuation of intracerebral hemorrhage using aspiration-irrigation technique has showed significant reductions in the hematoma volume with minimal intra-operative bleeding. Catheter-based evacuation in combination with use of recombinant tissue plasminogen activator (rt-PA) produces lysis and drainage of spontaneous ICH and intraventricular hemorrhage (IVH) rapidly with minimal major adverse events. Recent advances in the management of spontaneous ICH highlights potential advantages including safety and efficacy in clot lysis and reduction in hematoma volume especially with image-guided catheter-based drainage and concurrent use of rt-PA. Controlled trials are required to conclusively establish standard surgical techniques and rt-PA dosage, before incorporating minimally invasive surgery plus rt-PA, as a standard of care in patients with spontaneous ICH.

The Use of tPA in the Treatment of Frostbite: A Systematic Review.

The use of tissue plasminogen activator (tPA) for the treatment of frostbite has been reported and advocated, but its efficacy has not been well established. We conducted a systematic review to guide physicians on the role of tPA in the treatment of frostbite. Our hypothesis was that the use of tPA improves clinical outcomes, as measured by amputation rate. We searched MEDLINE (PubMed) and EMBASE for primary research articles on the use of tPA for the treatment of extremity frostbite. Information related to study design, outcomes, and complications was extracted. A total of 204 citations were screened, and then 35 abstracts and 24 reports were reviewed. Fifteen studies met the standard for final review. One randomized, prospective study; 3 cohort studies; 8 case series; and 3 case reports were found. A total of 208 patients were treated. Differences in protocols, inclusion criteria, and outcomes measures prevented combining the study results. In all the studies, the authors reported that the use of tPA was or may have been useful in reducing amputation rates or increasing tissue salvage. Complication rates ranged from 0% to 100%, with a combined rate of 13%. The quality of the evidence was low. Due to the low scientific quality of the studies, the efficacy of tPA in reducing amputation rates cannot currently be established. Randomized, prospective trials or well-controlled cohort studies are needed to better assess the role of tPA. Consideration should be given to limiting its use to research protocols.

Participation in Get With The Guidelines–Stroke and Its Association With Quality of Care for Stroke

Get With The Guidelines-Stroke (GWTG-Stroke) is an American Heart Association/American Stroke Association stroke-care quality-improvement program; however, to our knowledge, there has not been a direct comparison of the quality of care between patients hospitalized at participating hospitals and those at nonparticipating hospitals. To contrast quality of stroke care measures for patients admitted to hospitals participating and not participating in GWTG-Stroke. Subpopulation of 546 participants with ischemic stroke occurring during a 9-year follow-up of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a population-based cohort study of 30 239 randomly selected black and white participants 45 years and older recruited between 2003 and 2007. Of those with stroke, 207 (36%) were treated in a hospital participating in GWTG-Stroke and 339 in a nonparticipating hospital. Data were analyzed between July 29, 2017, and April 17, 2018. Quality of care measures including use of tissue plasminogen activator, performance of swallowing evaluation, antithrombotic use in first 48 hours, lipid profile assessment, discharge receiving antithrombotic therapy, discharge receiving a statin, neurologist evaluation, providing weight loss and exercise counseling, education on stroke risk factors and warning signs, and assessment for rehabilitation. Participants treated at participating hospitals had a mean (SD) age of 74 (8) years and 100 of 207 were men (48%), while those seen at nonparticipating hospitals had a mean (SD) age of 73 (9) years, and 161 of 339 were men (48%). Those seen in participating hospitals were more likely to receive 5 of 10 evidence-based interventions recommended for patients hospitalized with ischemic stroke, including receiving tissue plasminogen activator (RR, 3.74; 95% CI, 1.65-8.50), education on risk factors (RR, 1.54; 95% CI, 1.16-2.05), having an evaluation for swallowing (RR, 1.25; 95% CI, 1.04-1.50), a lipid evaluation (RR, 1.18; 95% CI, 1.05-1.32), and an evaluation by a neurologist (RR, 1.12; 95% CI, 1.05-1.20). Those seen in participating hospitals received a mean of 5.4 (95% CI, 5.2-5.6) interventions compared with 4.8 (95% CI, 4.6-5.0) in nonparticipating hospitals (P < .001). These data collected independently of the GWTG-Stroke program document improved stroke care for patients with ischemic stroke hospitalized at participating hospitals.

Endovascular management for tandem occlusions of anterior cerebral circulation.

Objectives:To compare the endovascular approaches and techniques used to treat tandem occlusions of anterior cerebral circulation.Methods:A literature review was carried out using PubMed to review the studies that described endovascular therapies for patients with tandem cerebral occlusions.Results:A total of 106 patients (median age: 64 years; range: 18-90 years) were identified. The median National Institutes of Health Stroke scale score at the time of admission for 104 patients was 16.5 (standard deviation [SD] ±5.7). The mean times and ranges from symptom onset to recanalization were 396.85 minutes (range: 120-1,574 minutes) and from groin puncture to recanalization were 80.3 minutes (range: 14-180 minutes). The mean outcome modified Rankin scale (mRS) score was 2.31 (SD ±2.2), and 61.3% of patients had an outcome mRS score ≤2. Moreover, 80% of patients with a groin puncture-to-recanalization time of ≤60 minutes had a mRS score ≤2 compared to 51.5% of patients with longer times (p=0.02). Despite that only 11.3% of patients underwent a retrograde approach, 81.8% of them had an outcome mRS score ≤2 compared to 60.8% of patients with an anterograde approach (p=0.023).Conclusion:A groin puncture-to-recanalization time of <60 minutes and a retrograde approach were shown to be favorable prognostic factors in terms of mRS score. The use of intravenous tissue plasminogen activator was associated with higher Thrombolysis In Cerebral Infarction scores, but not superior prognosis based on mRS.

Longer stent retrievers enhance thrombectomy performance in acute stroke

BackgroundLonger stent retrievers have recently become available and have theoretical advantages over their shorter counterparts. We aim to evaluate whether stent retriever length impacts reperfusion rates in stroke thrombectomy.MethodsThis was...

PCV92 - Association Between Recombinant Tissue Plasminogen Activator and In-Hospital Mortality/30-Day Readmission Among Mechanical Thrombectomy Patients: A Retrospective Cohort Study

Mechanical thrombectomy (MT) yields substantial revascularization success rate in ischemic stroke treatment for patients with large vessel occlusions. The present study evaluates the association between recombinant tissue plasminogen activator (rt-PA) use and in-hospital mortality or all-cause 30-day unplanned readmission among MT patients. A retrospective cohort study was conducted using data from Nationwide Readmissions Database (NRD) 2013-2014. Patients with primary diagnosis of ischemic stroke were included. MT and rt-PA were identified by appropriate procedure codes. Records with transfer, same day event status, <1 day of length of stay, and admissions in December were excluded. In-hospital mortality was identified as coded and readmission was calculated based on stroke quality measure documentation. Index admissions were followed within the same year. Multiple demographic, clinical, and hospital related covariates were adjusted in multivariable hierarchical logistic regression model. In the final cohort, 1,607 patients received MT/rt-PA and 1,712 patients received MT alone. Patients’ characteristics were approximately similar between groups (median age of 70 and 50% female). Mortality and readmission incidences in MT/rt-PA vs. MT group were 15.7% vs. 18.7% and 13.2% vs. 11.7%, respectively. The adjusted odds ratio for the mortality and readmission outcomes were 0.78 (0.65-0.95) and 1.26 (0.99-1.61), respectively (MT as reference). Use of rt-PA was associated with lower risk of in-hospital mortality. Hence, rt-PA should still be considered as a first line treatment option for MT eligible patient.